The Inner Work of Physician-Patient Relationship…And Other Things

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A couple of weeks ago I met my new medical students. These 10-12 trainees will be my small group for the next two years. We will meet monthly to discuss the soft stuff of medical training—hierarchy, tribalism, death and dying, medical errors, difficult patients, etc. Some call it “third year medical student support group.” This is my 6th year of the pleasure and privilege (I inherited my first group halfway through, when their previous preceptor moved out of state).

With each successive group I am ever more amazed at the students’ level of insight. They articulate compassion, humility, and maturity that I don’t think I had at their level of training. Or maybe it’s because we did not have classes like this to explore such things when I came up (or maybe I don’t remember?). More and I more I see my role as facilitator more than teacher. I am not here to impart medical knowledge. Rather, it is my job to stimulate exploration, conversation, and meaning. It’s so freeing, really—there is no standardized test to teach to. And yet I see it as my responsibility to help prepare these gifted young people to face the greatest challenge and reward of the profession: human relationships.

I feel no fear or trepidation. We cannot ‘fail’ at this class, any of us. Because the point of it is simply for everybody to participate, contribute, consider, and learn—myself included. Each month the students are given questions to answer in the form of a blog post. For example, “Recall an example of inspiring or regrettable behavior that you witnessed by a physician. Describe the situation, and its impact on you, the team, and/or the patient.” I read them all and facilitate discussion, tying together common themes and asking probing questions. My primary objective is to help them maintain the thoughtfulness and humanity that led them to medicine in the first place. Medical training has evolved in the past 20 years, for the better in some ways, not so much in others. One way we do much better nowadays is recognizing the hidden curriculum, and shining light on its effects, both positive and negative, through classes like this.

We all have those teachers who made a difference in our lives—or at least I hope we all do. I have multiple: Mrs. Cobb, 4th grade; Mr. Alt, 7th grade math; Ms. Townsend (now Ms. Anna), 7th grade English; Ms. Sanborn, 7th grade social studies; Mrs. Stahlhut, 9th grade geometry; Mrs. Summers, 10th grade English; Coach Knafelc, varsity volleyball; Dr. Woodruff, primary care preceptor; Dr. Roach, intern clinic preceptor; Dr. Tynus, chief resident program director. My mom is one of these teachers, also. She leads nursing students in their clinical rotations. I have seen her student feedback forms—they love her. And it wasn’t until I heard her talk about her students that I realized why they love her and what makes her so effective—she loves them first. Teaching is often compared to parenting. Our parents, at their best, see our potential and love us into our best selves. They cheer us, support us, redirect us, and admonish us. They show us the potential rewards of our highest aspirations. If we’re lucky, they role model their best selves for us to emulate.

All of my best teachers did (do) this for me. I’m friends with many of them to this day, and I still learn from them in almost every encounter. I love them because I feel loved by them. They held space for my ignorance and imperfections. I always knew that they knew that my best self was more than the last paper I wrote, the last test I aced, or the last patient encounter I botched. To them, my peers and I were not simply students. We were fellow humans on a journey of mutual discovery, and they were simply a little farther along on the path.

This is my aspiration as a teacher, to live up to the example of all those who loved me into the best version of myself today. This kind of love allows for growth and evolution, from student to colleague, to friend, and fellow educator. This is not something attending physicians typically express to medical students, positive evolution of medical education notwithstanding. But when I met this new group, I was overcome by love for them. So I told them. “If you take away nothing else from our two years together, I want you to have felt loved by me. I wish to love youinto the best doctors you can be. That is my only job here.” Or something like that. It was impulsive and possibly high risk. But it was the most honest thing I could say in that moment, my most authentic expression of my highest goal for my time with them. I only get to see them once a month, and I want them to be crystal clear about what I am here to do. We have lots to cover these two years, so much to learn and apply. And love is the best thing I can offer to hold us all up through it.

What did I write recently about staying off of Facebook and minimizing my social media exchanges? How fascinating, look what I just did—spent the last two hours on Facebook! I also write about trying, falling down, and trying again… So this is me both falling down (in my attempt to stay off) and trying again (to engage meaningfully).

The holidays are coming, yay! …And, not so yay! The conversations we have with friends and family in the next 6 weeks or so have enormous potential—for division as well as connection. Personally, I feel optimistic. I plan to evoke my core values of open-mindedness, empathy, and integrity. I want to look back on the gatherings with gratitude and deeper connection. So today I share with you all the things I have read (today—see? I endure Facebook for your benefit! teeheehee) that have helped me. These pieces validate, challenge, reassure, alarm, question and motivate me to Hold the Space, Stay on the Path, and Seek Love. Please share yours, also!

Posts by Michelle at The Green Study, reminding us that internal conflict is normal in the face of world events such as ours, with concrete suggestions for actions that align with core values: “We cannot strengthen our character unless it is tested. We cannot defend our freedoms unless they are threatened. We cannot become better writers or artists or humans unless we have obstacles to overcome.”

A gentle message from fellow blogger John Pavlovitz: “Friend, however you choose to navigate these holidays, know that it’s the right way. Give yourself permission to pretend or confront or abstain as you need to, and forgive yourself later if you decide you chose poorly. You’re probably going to get it wrong or at least feel like you did.

“But remember too, to save a little of that mercy for those who sit across the table from you or those who choose not to. They’ll be doing the best they can too.”

And finally, the Prayer of Maimonides, the twelfth century physician and philosopher:

These holidays, wish me persistence and ‘stubborn gladness,’ as Liz Gilbert calls it. I wish you all the same!

Today I watched this video of Trump supporters at his rallies. Their words, actions, and expressions represent the basest human emotions. I posted the video to my Facebook page, commenting:

(Donald Trump incites rage and hate) in his followers. He stokes the worst in people. He provokes the emotional states that preclude rational thought and reasonable behavior–he is the king of emotional hijacking. Nobody ever makes a good decision while emotionally hijacked; that is when relationships and connection are destroyed, often violently and permanently.

And here’s another irony: We non-supporters are similarly hijacked by his belligerence. He and his supporters incite us to rail against them all, collectively and wholly as individuals, as racists, bigots, idiots, haters, etc. Name-calling is the easiest and most convenient way to separate ourselves from what we disdain, what we fear, and what’s too uncomfortable to tolerate. But how does this help anything?

On my last blog post I wrote:

I intend to avoid:

-Speaking and writing in sweeping generalizations

-Following snap judgments about groups, or individuals based on their group membership

-Labeling and shaming people or groups as ‘racist,’ ’ignorant,’ ‘stupid,’ ‘lazy,’ etc.

Today I wrote about Trump’s supporters:

I’m trying not to label and pigeon-hole these people, trying not to judge them and discard them, just by what I see here. That only advances the exact mentality I seek to reverse: more separation, more hatred, more “you are less than me, you don’t matter.”

I guess I have to keep reminding myself.

I can hardly imagine what it would be like to sit down, one-on-one, with someone who sincerely supports a Donald Trump presidency, and have a conversation about it. But I can easily imagine talking to a Trump supporter about the trials and joys of parenting, the breakneck evolution of technology, and a mutual love of Marvel movies. Who knows, maybe I already do.

I think most of my friends know my political persuasion. Most of them also share it. But probably more than I realize don’t share it, and we avoid talking about it. Why? Because it’s uncomfortable. We don’t trust ourselves to avoid the emotional hijacking. We’re afraid we’ll say something we’ll regret and damage the relationship. Or (and), we see the only objective of such conversations as trying to change the other person’s mind, or having our mind changed, which feels at the same time futile and scary. So our avoidance of the hard, uncomfortable conversations is an attempt to maintain connection (with ourselves as well as one another). We intrinsically understand that our relationships are important. So we limit our conversations to topics on which we agree.

At this time in our human evolution, however, we are called to do more. It’s too easy to live in the echo chambers of like-minded friends and media sites. It’s too easy to filter our perceptions through repetition and reinforcement, to think that our point of view is the only one, or worse, the only right one. It’s too easy to label others as wholly racist, sexist, bigoted, idiotic, communist, misogynist, mindless, right-wing, extremist, or evil, based on impulsive interactions in comment sections on a blog or Facebook post. It is simply too easy to fall victim to premature judgment and conviction based on skewed and incomplete evidence. We are called to so much more. We are called to the hard conversations, the interactions that require effort and persistence. Why? Because the rewards of this work are understanding, compassion, empathy, connection, and love.

My friend wrote to me, “We have to do this work for your beautiful children.” Yes, my dear friend, for all of our beautiful, innocent children. Let us model for them what it means to Hold the Space for Connection, even, and especially, when it’s hard. This is the work we are called to do.

OH, this is a hard one. Okay, Okay, I just have to write it. And OMG, I am now two letters behind!

Oppose, Dictionary.com:

To act against or provide resistance to; combat.

To stand in the way of; hinder; obstruct.

To set as an opponent or adversary.

To be hostile or adverse to, as in opinion: to oppose a resolution in a debate.

To set as an obstacle or hindrance.

To set against in some relation, especially as to demonstrate a comparison or contrast: to oppose advantages to diadvantages.

To use or take as being opposite or contrary.

There is so much Opposition in our world now. I’m thinking specifically of politics. Like many of my blogging friends here, I eschew writing about politics because it can have unintended consequences and distract from the intent of this blog. I have alluded to it (Obtusely) here, and commented on another blog here. Mostly, I don’t feel qualified to comment on politics. But a Facebook post I wrote a few days ago keeps nagging at me to be shared, and I have struggled around the best way to present it. So here goes.

When I look at the list of definitions of oppose, I feel tired. When I think of the energy it takes to constantly stand against something, I feel listless and drained. Fighting, resisting, combatting, Obstructing, standing in the way, hindering, disputing, dissenting, contradicting—it’s exhausting. I think of times when I meet someone new and all they talk about are the things they hate, that they can’t stand, that they want changed. I cannot wait to get away and find levity. There are two main consequences of the oppositional mindset that put me off:

Polar Isolation

Oppositional mindset pushes people apart—to extremes. I think now of my Facebook friends who post incendiary words and images. They blame, shame, ridicule, mock, and degrade Others. By others I mean those who do not share a common economic background, political ideology, religion, skin color, profession, or even parenting style. When I see these, I conduct an internal debate. Part of me wants to engage, to call my friend out for posting something Offensive, distasteful, unprofessional, or unkind. I try only to be friends on Facebook with real-life friends, so I know these people are not offensive, unkind people in general. But each time one of them posts something deriding a group to which I belong, I feel hurt. So I want to ask them, what are they really thinking? Would they say these things to me in person? But I know that social media is a poor venue to hold these conversations. So I almost always scroll over. Every time, though, there is residue on my figurative shoe from stepping over these posts. I have to work harder to think of my friend in the same positive light. I wonder whether we really do share values like I thought we did—because one of my highest values is to be kind to others. I feel a distance now that I have chosen deflection rather than engagement. It feels sad and lonely.

This is not to mention the escalating verbal wars waged by our politicians today. Suffice it to say, I have stopped watching the news and listening to the radio. I curate my information in small doses and avoid sensational headlines. Everybody is out to paint the Others as dangerous, untrustworthy, less than.

When all we hear from our Opponents is how much they hate us, how stupid they think we are, how they wish we would shut the f*** up, we will do one of two things. We will disengage, or we will engage with acute and increasing hostility. Either way, we push one another further and further apart, and we end up living in polar opposition. And as we know, conditions at the ends of the earth are harsh. It’s a desolate and heartbreaking way to live.

Rigidity, Immobility, and Stagnation

The other consequence of a singular focus on that which we oppose is a complete and total lack of progress. Two examples come to mind:

My child is jumping on the sofa. “Stop that,” I say, “don’t jump on the sofa.” She stops momentarily, then starts again in a few minutes, moved by a spontaneous joy that I have long since forgotten. I keep repeating, “Stop that, do NOT jump on the sofa!” The focus remains on what I do not want. I keep a lookout, and each time she repeats the unwanted behavior my frustration mounts. I may employ negative consequences—the next time she jumps, I take away screen time, or a stuffed animal. The stakes climb and everybody gets tense.

I hate my body. I am 20 pounds overweight, I feel sluggish, none of my clothes look good, and it undermines my confidence. I keep thinking, I don’t want to be fat, I don’t want to be fat. So every time I’m faced with donuts that someone brought to work, every time I go out to eat with my friends, I brace myself to guard against behaviors that I know will make me more fat. I succumb sometimes. I feel shame. I keep thinking to myself, What’s wrong with me, why do I keep doing things that will keep me fat, when I don’t want to be fat?

There is a saying, “Energy flows where attention goes.” I don’t know who said it first. When we focus on what we don’t want, there we remain. Even when it’s what we oppose, if we continuously attend to it, precious little energy remains to spend on what we do want. This constant vigilance and guarding keeps us preoccupied with the problem, and impairs our ability to develop solutions. What if I changed my focus with my child, and let her know what I expect from her? “The sofa is for sitting. Can you please sit nicely on the sofa? How long can you sit still?” Now I’m generating movement toward something desirable. I’m making it a challenge, it could even be fun. Tension is diffused, and I might tap into that long lost joy a little. My self-talk around weight could also benefit from a subtle shift. The difference between I don’t want to be fat and I want to be healthy can be profound. The former keeps me fixated on and entrenched where I am. The latter helps me move toward a goal, gives me an aspiration. What does a healthy person do? She avoids the break room when donuts arrive, finds alternate routes to the bathroom. She takes the stairs rather than the elevator. She chooses salad more often than burgers. I start to envision my best self, and I feel motivated to pursue it (me).

Letting go of my oppositional mindset allows my creativity to shine through, and a world of possibilities may Open up before me.

Open, Dictionary.com:

Not closed or barred at the time, as a doorway by a door…

(Of a door, gate, window…) set so as to permit passage through the opening it can be used to close.

Having no means of closing or barring: an open portico.

Having the interior immediately accessible, as a box with the lid raised or a drawer that is pulled out.

Relatively free of obstructions to sight, movement, or internal arrangement: as an open floor plan.

Constructed to as to be without cover or enclosure on the top or on some or all sides: an open boat.

Having relatively large or numerous spaces, voids, or intervals: an open architectural screen; open ranks of soldiers.

Letting go of opposition means Opening ourselves to new possibilities of thought, engagement, Outcomes, and connection. I believe my friends are kind and generous at heart. I can still oppose their offensive expressions. If I do it with an open heart, ready to hear their point of view, withholding judgment and honestly listening for understanding, then I can maintain our relationships, even deepen them. If I can make them feel seen, heard, understood, accepted and loved, despite our differences, then they will be more likely to extend me the same courtesy.

Being open means being vulnerable. Just because I Offer openness and understanding does not mean my counterpart will reciprocate. I could be rejected, ridiculed more, hurt more. These are the risks and costs of openness.

But what of the benefits? What if my openness actually creates a space for communication and mutual understanding? What if my friends and I can lead by example? Could we start a movement toward taking time to hear one another, seeing different points of view, and holding multifaceted perspectives? Humans and our experiences are complex. We cannot easily be distilled into soundbites, headlines, cartoons, and labels. We should not accept such oversimplifications—we should Oppose them. And at the same time we need to stand Open to the validity of our fellow citizens’ experiences. We need to remain Open to the possibility—the certainty—that we really do share common values, goals, and hopes. We need to work harder to hold our hearts Open to one another, reach out and come in from the cold, polar regions, and strive together for a better world for all of us. We cannot hold hands with clenched fists (another quote, no?). I would rather hold hands.

***

Here is the video that triggered my Facebook post of April 15, 2016, and the actual post:

I love Bernie. Also, though, I am starting to notice that his severe criticism of ‘the rich’ and his characterization of them as greedy as a group, oversimplifies. It does so IN THE SAME WAY AS DOES THOSE WHO CHARACTERIZE POOR PEOPLE AS LAZY. There are greedy rich people. There are also lazy rich people. There are also greedy and lazy poor people.

I agree with Bernie’s core values and his consistently stated vision for our future. I understand that his proposed policies may be unrealistic and unattainable in the foreseeable future, or maybe even ever. But he gives me something deeply meaningful to strive for, and that is the kind of leader I will follow. Even if we never get there, I will happily trudge the path *in the direction* of said future, because it’s where I want to go. I do not hear or see a clearly stated vision or aspiration from the Republicans. Bernie inspires me to be a better person, to make my best contribution to society.

We all have a desire to make a contribution. Psychology research over literally DECADES tells us that human nature is wired to be both productive and connected. So these premises that some of us are innately lazy and live for handouts, and others of us are conversely inclined to accumulate wealth only for ourselves and for its own sake, are not only severely misguided, they are dangerous. These toxic assumptions are exactly what keep each side permanently entrenched in opposition. Assumptions turn into accusations, which then engender mutual defensiveness, then offensiveness. It’s no wonder we have devolved into the current political morass.

I want Bernie to soften his language and invite the rich into conversation, collaboration, innovation, and creativity around solving the problems of inequality and disparity.

I want Republican leaders to moderate the voices in their party who blame the poor as personal failures and the sole architects of their downtrodden situation.

I bet most rich people really do care about the poor, just like I believe most poor people really do want to work and be productive members of society.

How much more could we do, how much better could we be, how much movement could we achieve, based on these assumptions instead?

One year ago yesterday I launched this blog, Happy Blogoversary to me! 😀

It started as a platform to explore ways to reconnect patients and physicians in the increasingly divisive healthcare system. And while that idea still stands central to the theme of the blog, I soon realized a much larger and more important principle: The best practices apply across all relationships, not just doctor-patient relations. The more I write, read, and explore, the bolder I have grown in my writing.

The very best outcome (so far) of starting this blog has been the LOVE I have received from others around it. From the beginning, fellow bloggers have engaged, welcomed, encouraged, challenged, and nurtured me. My friends and family have also held me up—following me via email, commenting on Facebook and the blog itself. A vast community of support has stood up around me as I took this risk to share my mind publicly. If they looked down on blogging, they kept it to themselves and encouraged me anyway. If they thought I wouldn’t stick with it, I imagine they secretly wished me persistence, and then grace if I failed. Because of all of these people, I have confidence to continue striving to bring forth the best in me, to share with everybody, in the hopes of creating something meaningful.

What if everybody had this chance? What if every time someone wanted to do something bold and new, we met them with this much LOVE, cheer, praise, and affirmation? Doing so does not mean blindly endorsing frivolous endeavors and wasted energy. We can always offer LOVE along with tactful words of truth and pragmatism. Even when, or especially when, projects fail terrifically, everybody can learn and grow. LOVE from others at the outset makes us more resilient to failure. LOVE from others at the moment of failure, as opposed to ridicule, shame, and sarcasm, makes us humble, grateful, and more brave, as opposed to defensive, angry, and humiliated.

Adequate words do not exist to express my deepest and most sincere gratitude to all who have LOVED me throughout my life, including those who have LOVED me through my blogging adventure so far. May I pay it forward, and find ways to LOVE others whenever I have the chance. If I can do that, then I will truly contribute to making the world a better place.

I meant to reblog this beautiful piece by Jodi yesterday! But my airport Wifi timed out before I could actually post…😣

Jodi has inspired me to reveal my theme for the upcoming Blogging A to Z Challenge! 26 posts starting April 1, one for each letter of the alphabet, indeed around More And Less. I plan to explore meaningful words to apply to perceptions, attitudes, behaviors, and relationships. For instance, how would the world look and feel if we all Adored more and Attacked less? Or Beautified more and Brandished less? I have an extensive and growing list of words, woo hooooo! 😄 So, we’ll see how it goes. Hope you will stop by and check it out!